Provider Demographics
NPI:1609340942
Name:TRASK, TESSA VIRGINIA PEGRAM (MA LPC)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:VIRGINIA PEGRAM
Last Name:TRASK
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 W WIMBLEDON DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2918
Mailing Address - Country:US
Mailing Address - Phone:302-528-4856
Mailing Address - Fax:
Practice Address - Street 1:507 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7209
Practice Address - Country:US
Practice Address - Phone:843-619-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6942101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC646733559OtherHPSO